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CHAPTER 9
Communication and
the Clinical
Interview
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
The Communication Process
Berlo’s classic communication model (1960):
•Communicating with another is needed (stimulus).
•Person who is sending the message (sender)
initiates the contact.
•Message is information sent or expressed.
•Message can be sent through a variety of media:
auditory, visual, tactile, smell, or any combination.
•Person receiving the message (receiver) interprets
the message and responds by providing feedback.
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
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Therapeutic Communication
 Social relationships are different from therapeutic
relationships
 Therapeutic communication is professional, goal-directed,
and scientifically based
•
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Therapeutic Communication
(continued)
It is often during the psychiatric rotation that students
discover the utility of therapeutic communication and
begin to rely on techniques they once considered
artificial. With continued practice, students will develop
their own style and rhythm, and eventually these
techniques will become a part of the way they
communicate with others.
•
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Therapeutic Communication
(continued)
Will saying the wrong thing be harmful to the
patient? This is doubtful, especially if the intent is
honest, the approach is respectful, and the concern
for the patient is genuine. Communication is up
to 90% nonverbal, and individuals pay attention
to the intent.
•
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Case Study
• A new nurse on a psychiatric unit wants to effectively
communicate in a therapeutic relationship with a patient.
• What are some things that will help this communication?
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Factors That Affect Communication
• Personal factors
• Environmental factors
• Relationship factors
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Relationship Factors in Communication
• Symmetrical relationship:
– Equal: Friends or colleagues
• Complementary relationship:
– Unequal: Difference in status and power, such as
between a nurse and patient or between a teacher and
student.
• Relationship is characterized by inequality (one
participant is superior to the other).
•
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Concept Discussion
In the United States, capitalism intimately ties systems of
privilege (high-power groups) with the systems of
oppression (low-power groups) through economic control.
Since high-status groups hold more power, they have more
control over low-status groups. One way that power groups
retain control (unequal) is through stereotypes, prejudice,
and biases. In other words, stigma plays a big role in keeping
relationship factors out of balance. (Hays, 2008)
•
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Verbal Communication
• All words a person speaks
• Communicates
• Beliefs and values
• Perceptions and meaning
• Can convey
•
•
•
•
Interest and understanding
Insult and judgment
Clear or conflicting messages
Honest or distorted feelings
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Nonverbal Communication
• Tone of voice
• Emphasis on certain words
• Physical appearance
• Facial expressions
• Body posture
• Amount of eye contact
• Hand gestures
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Non-Verbal Communication
12
Discuss Nonverbal Communication
(Depicted Below)
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Nursing Process: Implementation
• Therapeutic communication techniques are specific
responses that encourage the expression of feelings and
ideas and convey acceptance and respect.
• Active listening means using all the senses (hearing, vision,
touch, taste and smell) while being attentive to what a
patient is saying both verbally and nonverbally.
• SOLER (next slide)
Active Listening: SOLER
• Sit facing the patient at eye level
• Observe an open posture
•Lean toward the patient
• Establish and maintain intermittent eye contact
• Relax
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Therapeutic Communication Techniques
• Tools for enhancing communication
• Using silence
• Active listening
• Listening with empathy
Table 9-2 Pg. 154-155
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Active Listening Principles
• The answer is always inside the patient.
• Objective truth is never simple.
• Everything you hear is modified by the patient’s filters and
your own filters.
• Feeling confused or uncertain is OK.
• Listen to yourself too.
Active Listening helps strengthen the patient’s ability to use
critical thinking to solve problems. By giving the patient
undivided attention, the nurse communicates that the
patient is not alone.
•
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Asking Questions and Eliciting Patient
Responses
• Open-ended questions
• Closed-ended questions
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Therapeutic Communication Techniques
•
•
•
•
•
•
•
•
•
•
•
Accepting
Giving recognition
Offering self
Offering general leads
Giving broad openings
Placing the events in time and sequence
Making observations
Encouraging description of perception
Encouraging comparison
Restating
Reflecting
(Continued.)
•
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Therapeutic Communication
Techniques—cont’d
• Exploring
• Giving information
• Seeking clarification
• Presenting reality
• Voicing doubt
• Seeking consensual validation
• Verbalizing the implied
• Encouraging evaluation
• Attempting to translate into feelings
• Suggesting collaboration
• Summarizing
• Encouraging formulation of plan
• Focusing
•
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Blocks to Therapeutic Communication
• Giving premature advice
• Minimizing feelings
• Being falsely reassuring
• Making value judgments
• Asking “why” questions
• Asking excessive questions
• Using clichés
• Giving approval—agreeing/cheerleading
• Disapproving—disagreeing
• Changing the subject
•
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Cultural Considerations: Negotiating barriers
• Four areas that may prove problematic for the nurse when
interpreting specific verbal and nonverbal messages of the patient
include the following:
1. Communication styles
2. Use of eye contact
3. Perception of touch
4. Cultural filters
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Compare and contrast the range of verbal and nonverbal
communication of your cultural group with two other cultural groups in
the areas of (a) communication style, (b) eye contact, and (c) touch.
Give examples.
Your
Culture
Culture
Other
Culture
Other
Culture
Communication
style
Eye contact
Touch
•
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Therapeutic Communication Goals
• Feel understood and comfortable.
• Identify and explore problems relating to others.
• Discover healthy ways of meeting emotional needs.
• Experience satisfying interpersonal relationships.
•
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Therapeutic Communication Goals
• Feel understood and comfortable.
• Identify and explore problems relating to others.
• Discover healthy ways of meeting emotional needs.
• Experience satisfying interpersonal relationships.
•
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Preparing for the Interview
• Pace
• Setting
• Seating
• Introductions
• Initiating the interview
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Attending Behaviors
Attending behaviors encourage talking.
• Maintain eye contact.
• Control vocal qualities (tone and speech rate).
• Face the person.
• Use encouraging gestures.
• Track verbal content; do not change the subject.
• Use open-ended vs. closed-ended questions.
• Asking why? may place a person on the defensive and
cause discomfort.
•
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Helpful Guidelines
• Speak briefly
• When you do not know what to say,
say nothing
• When in doubt focus on feelings
• Avoid giving advice
• Do not rely on asking questions
• Pay attention to nonverbal clues
• Focus on the patient
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Clinical Supervision
• Communication and interviewing are acquired skills
• Fosters professional growth and helps minimize the
development of nontherapeutic nurse-patient relationships.
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Process Recording
• Written record of a segment of the nurse-patient session that
reflects as closely as possible the verbal and nonverbal
behaviors of both patient and nurse
• Useful tool for identifying communication patterns
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Bathe Technique
• Background: What is going on in your life?
• Affect: How do you feel about what is going on?
• Trouble: What troubles you the most about this problem?
• Isolation of the key issues
• Handing: How have you been handling (coping) with this problem?
• Empathy: This must be very difficult for you.
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NURS
• Name the patient’s emotion (It seems as though the
constant headaches really get you frustrated.)
• Understand (I can see why you feel this way.)
• Respect (You’ve been through a lot and that takes courage.)
• Support (I want to help you get better.)
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Health Informatics
E-Health, E-Medicine, Telehealth
• Essentially, Telehealth is the use of electronic information and
telecommunication technologies that support long-distance clinical
health care, patient and professional health-related education, public
health, and health administration.
• Technologies include videoconferencing, the Internet, store-andforward imaging, streaming media, and terrestrial and wireless
communications (United States Department of Health and Human
Resources–Health Resources and Services Administration [USDHHSHRSA]—rural health).
• http://www.hrsa.gov/ruralhealth/about/telehealth
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E-Health, E-Medicine, Telehealth
• Telehealth can improve patients’ experience by reducing the need to
travel to hospitals when remote monitoring (e.g., ECG) and
videoconferencing is equally effective and cheaper. It has already
been used to manage patients in dermatology, cardiology and
neurology.
• Are valuable tools to access current psychiatric and medical
breakthroughs, diagnoses, and treatments.
• Most mental health issues do not get addressed because of a fear of
stigma, scarcity of health care providers in remote areas, and
difficulty leaving home (e.g., anxiety, physical limitations, lack of
transportation).
• Consequences from not seeking help can range from problems at
work, domestic violence, increased depression, and suicide.
•
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E-Health, E-Medicine, Telehealth—cont’d
• Department of Defense (DOD)
is interested in using and
expanding these services.
• Up to 25% of service members
screen positive for mental
health concerns.
• Telepsychiatric appointments
are offered.
• Wellness and resiliency
interventions are available,
especially in rural areas.
•
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Telehealth Technologies
• Intel™ developed a mobile
phone application that
mirrors cognitive behavioral
therapy (CBT).
• Touchscreen “Mood Map” for
Android and iPhone invites users to plot mood during the
day and view trends.
• The University of Colorado Hospital is using Skype to work
with children with autism and their families.
• Lacks reimbursement by third-party payers.
•
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Audience Response Questions
1.
As a nurse assesses a new client, the nurse makes sure the door
remains open. Which type of communication factor is this action?
A. Environmental
B. Relationship
C. Personal
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Audience Response Questions
2.
A nurse assesses a newly hospitalized client. Which
communication technique will the nurse use most?
A. Rapid, high-pitch voice tone
B. Closed-ended questions
C. Direct eye contact
D. Frequent touch
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